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' SAN J OAQUI:N CQiAV <br /> N a 1' <br /> }C PUBLIC EEALM SERVICES <br /> FN-VjRON]ygC N7,AL ED~ALM DIVISION <br /> FUALIC RECORDS RELEASE APPLICATION <br /> S�U �l <br /> rs Q APPI ICANI' PRONE NO ✓` _¢� <br /> ADDRESS <br /> AGENCYNAMEc1rJ ONE NO <br /> Q ADDRESS d <br /> B b 5 LEkD ArENQ Off. <br /> L Gr/ S• L <br /> I!� .0 <br /> 3 <br /> CD4 U� $T4 <br /> T, js No77CI~ Is SUHIECT TO TIDE REQUIMMENTS IDENTIFIED IN n-lfi PUBUC HEALTH <br /> SER%IICESIElti��rmONI,,A ETQTA.L}:E.rJ-TH DIVISION (EHA)?OL]CY 497-447,ORDINANCE CODB OF SAN <br /> MkQUIN COUNTY, EJ3D FEES AND SER17CE CHARGE RESOLUTIONS, STATE WATER CODE, <br /> G0VE:RN',.LNT COD); AND irk EV"3DENC I-C0DF-- <br /> I. A I•S,4x7 Mlj OF TEN (i4) PREI'flSE A:)DRFSSBS PIR REQUEST. <br /> 2. PUkUC FIL1S/RECO.;�DS REYIEIV n.E By M?0Iti'UJEN`r oNLY. APPOINTMENTS ARE <br /> ArZRANGED BY CALUNG G'03)468-0340- OF-TICE HOURS FOR APPOI9T},1I=NTS ARE SC14EDUI ED <br /> MCN-DAY THnU FRIDAY FXCLVDING HOLIDAYS, 9:00 A.M.TO 1:;p4 NOON A,ND JM P.M. TO 4:30 <br /> P.M. <br /> a. A PUBLIC RE-COROS I2LEASF APPLICATION AND A NON-REFU'NDABl-E DEPOSIT OF 578.01 <br /> I5 R1 QL7RED. DEPOSITS '9,:j LL BE RJrTLktiED TO T - .kPPUCANT IF THE FILI VRKOADS ARC <br /> NGT AVAJL-A--LS +}`IT}-311 37-%£ CUSTODY OF THF-F)4D- <br /> 4. THE ABOVE IDFNMF)Eb DEPOSIT IS APPLIED TOWARDS THE TOTAL FILE RE.YIEW FEE <br /> C]4A GF. THE SA.LAjgCE OF Vp- CHARGES AR.I; DUE.A?KD PAYABLE F OE TO REN9EVING THE <br /> DOCLIM>rit'T(S�. <br /> 5, PUBUC FILES/RECO.RZUS NOT RETURNED IN T"HE SA3 JE CONDITION AS R2CFlVI=b R'7LL BE <br /> CORREC-I-Ei7 BY TrlE F.HD STAFF AT TNI; ID,PENSE OF THE A.PPL]CANT. THJS ADDMONAL <br /> SEXiFICE.WILL BI; 131L=--DD TO TAB A-PPLICANry FOR PAYMENT, ' <br /> 6. ORIGINAL.I?UBLIC FILU/RECOPDS SHAJ-L NOT BE REMOVED FROM T14E E14D PRE)%flSES. <br /> SIGNATURE OF AMI CANT 'Z DATE <br /> SIGNATURE OF RELEASING OFFICIAL ��^DATE <br /> ER 00 14 (REV I V92) <br /> '9t 4-D z 1C) <br />